<!DOCTYPE html>
<html>
<title>Unsubscribe</title>
<style>
    input {
        display: block;
        margin-bottom: 15px;
    }
    
    input[type="submit"] {
        padding: 6px 4px;
    }
    
    label {
        display: inline-block;
        float: left;
        width: 100px;
    }
    
</style>
<body>
	<form method="post" action="https://secure.axes-payments.com/cgi-bin/automatic_recurring/ar_member.cgi" target="_blank">
		<label>Site Code*</label>
		<input type="text" name="site_code" value="A019000063">
		<label>Act*</label>
		<input type="text" name="act" value="unsubscribe">
		
		<!-- <label>Auth Key*</label>
		<input type="text" name="auth_key" value="1234"> -->
		
		<label>User Id*</label>
		<input type="text" name="user_id" value="<?php echo rand(1, 10000)?>">
		<label>Email</label>
		<input type="text" name="email" value="tucq88@gmail.com">
		<input type="submit" value="subscription">
	</form>
</body>
</html>